George Washington was Inaugurated in New York City


On Thursday, April 30, 1789, on the balcony of Federal Hall in New York City, New York George Washington was inaugurated as the first President of the United States. Thus ends the final chapter of a fascinating book entitled, “A Brilliant Solution: Inventing the American Constitution,“ by Carol Berkin. This is a must read for anyone fascinated by the foundations of the American experience in governing. But most important to note is the profound insight our founders had into human behavior and the human psyche, and the intelligent and prescient controls they put in place to avoid concentration of power. Our goal is to share a copy of the book on your next visit to our offices.


For more information about Target Health contact Warren Pearlson (212-681-2100 ext. 165). For additional information about software tools for paperless clinical trials, please also feel free to contact Dr. Jules T. Mitchel. The Target Health software tools are designed to partner with both CROs and Sponsors. Please visit the Target Health Website.


Joyce Hays, Founder and Editor in Chief of On Target

Jules Mitchel, Editor



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Figure A shows the location of the heart and a normal heart and pericardium (the sac surrounding the heart). The inset image is an enlarged cross-section of the pericardium that shows its two layers of tissue and the fluid between the layers. Figure B shows the heart with pericarditis. The inset image is an enlarged cross-section that shows the inflamed and thickened layers of the pericardium.

Graphic credit: National Heart Lung and Blood Institute (NIH) – National Heart Lung and Blood Institute (NIH), Public Domain,


Pericarditis is inflammation of the pericardium (the fibrous sac surrounding the heart). Symptoms typically include sudden onset of sharp chest 1) ___. The pain may also be felt in the shoulders, neck, or back. It is typically better sitting up and worse with lying down or breathing deep. Other symptoms may include fever, weakness, palpitations, and shortness of breath. Occasionally onset of symptoms is gradual. The cause of pericarditis is believed to be most often due to a viral infection. Other causes include bacterial infections such as tuberculosis, uremic pericarditis, following a heart attack, cancer, autoimmune disorders, and chest trauma. The cause often remains unknown. Diagnosis is based on the chest pain, a pericardial rub, specific 2) ___ changes, and fluid around the heart. Other conditions that may produce similar symptoms include a heart attack.


Treatment in most cases is with NSAIDs and possibly colchicine. Steroids may be used if those are not appropriate. Typically, symptoms improve in a few days to weeks but can occasionally last months. Complications can include cardiac tamponade, myocarditis, and constrictive pericarditis. It is a less common cause of chest pain. About 3 per 10,000 people are affected per year. Those most commonly affected are 3) ___ between the ages of 20 and 50. Up to 30% of those affected have more than one episode. The characteristic pain of pericarditis includes substernal or left precordial pleuritic chest pain with radiation to the trapezius ridge (the bottom portion of scapula on the back), which is relieved by sitting up and bending forward and worsened by lying down (recumbent or supine position) or inspiration (taking a breath in). The pain may resemble the pain of angina pectoris or 4) ___ attack, but differs in that pain changes with body position, as opposed to heart attack pain that is pressure-like, and constant with radiation to the left arm and/or the jaw. Other symptoms of pericarditis may include dry cough, fever, fatigue, and anxiety. Due to similarity to myocardial infarction (heart attack) pain, pericarditis can be misdiagnosed as an acute myocardial infarction (a heart attack) solely based on the clinical data and so extreme suspicion on the part of the diagnostician is required. Acute myocardial 5) ___ electrocardiogram (heart attack) can also cause pericarditis, but the presenting symptoms often differ enough to warrant diagnosis.


The classic sign of pericarditis is a friction rub heard with a 6) ___ on the cardiovascular examination usually on the lower left sternal border. Other physical signs include a patient in distress, positional chest pain, diaphoresis (excessive sweating), and possibility of heart failure in form of pericardial tamponade causing pulsus paradoxus, and the Beck’s triad of low blood pressure (due to decreased cardiac output), distant (muffled) heart sounds, and distension of the jugular vein (JVD). Pericarditis can progress to pericardial effusion and eventually cardiac tamponade. This can be seen in patients who are experiencing the classic signs of pericarditis but then show signs of relief, and progress to show signs of cardiac tamponade which include decreased alertness and lethargy, pulsus paradoxus (decrease of at least 10 mmHg of the systolic blood pressure upon inspiration), low blood 7) ___ (due to decreased cardiac index), (jugular vein distention from right sided heart failure and fluid overload), distant heart sounds on auscultation, and equilibration of all the diastolic blood pressures on cardiac catheterization due to the constriction of the pericardium by the fluid. In such cases of cardiac tamponade, diagnostic tools such as an ECG or Holter monitor will then depict electrical alternans indicating wobbling of the heart in the fluid filled pericardium, and the capillary refill might decrease, as well as severe vascular collapse and altered mental status due to hypoperfusion of body organs by a heart that cannot pump out 8) ___ effectively.


The diagnosis of tamponade can be confirmed with trans-thoracic echocardiography (TTE), which should show a large pericardial effusion and diastolic collapse of the right ventricle and right atrium. Chest X- 9) ___ usually shows an enlarged cardiac silhouette (“water bottle“ appearance) and clear lungs. Pulmonary congestion is typically not seen because equalization of diastolic pressures constrains the pulmonary capillary wedge pressure to the intra-pericardial pressure (and all other diastolic pressures).


In the developed world viruses are believed to be the cause of about 85% of cases. In the developing world tuberculosis is a common cause but it is rare in the developed world. Viral causes include coxsackievirus, herpesvirus, mumps virus, and HIV among others. Pneumococcus or tuberculous pericarditis are the most common bacterial forms. Anaerobic bacteria can also be a rare cause. Fungal pericarditis is usually due to histoplasmosis, or in immunocompromised hosts Aspergillus, Candida, and Coccidioides. The most common cause of pericarditis worldwide is infectious pericarditis with 10) ___.






Myocarditis and Pericarditis: Khan Academy


Answers: 1) pain; 2) electrocardiogram; 3) males; 4) heart; 5) infarction; 6) stethoscope; 7) pressure; 8) blood; 9) -ray; 10) tuberculosis


Frederic Chopin’s Cause of Death

Chopin plays for the Radziwills, 1829 (painting by Henryk Siemiradzki, 1887)

Credit: Henryk Siemiradzki –, Public Domain,


In 2014, a team of medical experts received permission to remove Polish genius, Frederic Chopin’s preserved heart from the Holy Cross Church in Warsaw, where it had ultimately been interred, and examine it for clues that might shed light on the mysterious ailment that led to Chopin’s death at the age of 39. The diagnosis, published in the American Journal of Medicine this past week, is the latest and most convincing foray into the long-running dispute over the likely cause of Chopin’s slow decline and death in his 30s. This published paper suggests that the composer died of pericarditis, a complication of chronic tuberculosis. Other suggested causes of his debilitation and death have included the inherited disease cystic fibrosis; alpha-1-antitrypsin deficiency, a relatively rare genetic ailment that leaves individuals prone to lung infections; and mitral stenosis, a narrowing of the heart valves. Used for the recent analysis and diagnosis was the great composer’s heart, stored in a jar of cognac for 170 years.


An autopsy was performed to try to solve the mysterious cause of the 39-year-old’s death. His heart was removed and later stored in a jar of cognac, then interred in a church pillar in Poland. But when the researchers recently examined the jar containing Chopin’s heart – kept in the crypt of the Holy Cross church in Warsaw – they noted the heart was covered with a fine coating of white fibrous materials. In addition, small lesions were visible, the telltale symptoms of serious complications of tuberculosis, concluded the team. “We didn’t open the jar,“ team leader Professor Michael Witt of the Polish Academy of Sciences told the Observer. “But from the state of the heart we can say, with high probability, that Chopin suffered from tuberculosis while the complication pericarditis was probably the immediate cause of his death.“


The new study is the latest chapter in the strange story of Chopin’s heart. After the composer died in October 1849 in Paris the rest of his remains were buried in the city’s Pere Lachaise cemetery, also the last resting place of Marcel Proust, Oscar Wilde and Jim Morrison. However, his status as a Polish national hero ensured that his heart became embroiled in controversy. Chopin’s health began to falter in the late 1830s, ultimately making it difficult for him to continue composing music. Over the years, a number of diseases have been named as the culprit of his physical decline, from cystic fibrosis to alpha-1-antitrypsin deficiency, a rare genetic condition that eventually leads to lung disease. According to a 2014 article by Alex Ross of the New Yorker, Ludwika Jedrzejewicz, Chopin’s eldest sister, smuggled the organ past Austrian and Russian authorities on her way to Poland, hiding the jar that held the heart beneath her cloak. The jar was subsequently encased in a wooden urn and buried beneath a monument at the Holy Cross Church.


In the early 20th century, Chopin, as one of Poland’s most famous native sons, became the focus of nationalist fervor in the country. During the WWII-era, Nazi occupiers recognized the symbolic significance of Chopin’s legacy and sought to block the performance of his music. But his heart was removed from the Holy Cross and given to the S.S. officer Heinz Reinefarth, who claimed to admire the composer and kept the heart safe at Nazi headquarters in Poland. The organ was returned to Holy Cross in 1945, where it remained until church officials and medical researchers collaborated to dig it up. The examination of the heart by Professor Witt and colleagues was the first since 1945. “We found it is still perfectly sealed in the jar,“ said Witt. “Some people still want to open it in order to take tissue samples to do DNA tests to support their ideas that Chopin had some kind of genetic condition. That would be absolutely wrong. It could destroy the heart and in any case, I am quite sure we now know what killed Chopin.“ The recent examination of Chopin’s heart is unlikely to quell discussion over the cause of his death. As Nature reports, the organ has never been tested for cystic fibrosis, another proposed cause of Chopin’s demise. And some scholars have cast doubt on whether the heart belonged to Chopin at all. But for now, the (possible) relic of the composer can rest undisturbed. Researchers will not be permitted to examine the heart again for another 50 years.

Sources: The Guardian; The Smithsonian; Wikipedia

Read more:


Chopin on His Deathbed, by Teofil Kwiatkowski, 1849, commissioned by Jane Stirling. Chopin is in the presence of (from left) Aleksander Jelowicki, Chopin’s sister Ludwika, Princess Marcelina Czartoryska, Wojciech Grzymala, Kwiatkowski. Credit: Teofil Kwiatkowski –, Public Domain,


Funerary monument on a pillar in Holy Cross Church, Warsaw, enclosing Chopin’s heart.

Photo credit: Nihil novi – Own work, Public Domain,


Chopin’s grave in Paris

Photo credit: Auguste Clesinger – Marcin L., 26 December 2005, Public Domain,


Here are some favorite Chopin masterpieces.

Frederic Chopin – Prelude in E-Minor (op.28 no. 4)

Chopin Nocturne C sharp minor (1830) (Arjen Seinen).

Chopin Ballade in G Minor Scene; Pianist, Wladyslaw Szpilman

Chopin, Nocturne in C sharp Minor (1830); Pianist, Jan Lisiecki

Chopin Nocturne No. 20; Pianist, Wladyslaw Szpilman

Chopin Piano Concerto No 1 in E Minor; Pianist, Land Lang



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Low-fat Dietary Pattern and Pancreatic Cancer Risk in Women


Observational studies suggest that diet may influence pancreatic cancer risk. As a result, a study published in the Journal of the National Cancer Institute (18 August 2017) investigated the effect of a low-fat dietary intervention on pancreatic cancer incidence.


The Women’s Health Initiative Dietary Modification (WHI-DM) trial is a randomized controlled trial conducted in 48,835 postmenopausal women age 50 to 79?years in the United States between 1993 and 1998. Women were randomly assigned to the intervention group (n=19,541), with the goal of reducing total fat intake and increasing intake of vegetables, fruits, and grains, or to the usual diet comparison group (n=29,294). The intervention concluded in March 2005. The current study evaluated the effect of the intervention on pancreatic cancer incidence with the follow-up through 2014. In the intention-to-treat analyses, which included 46,200 women, there were 92 vs 165 pancreatic cancer cases in the intervention vs the comparison group (P =0.23). The multivariable hazard ratio (HR) of pancreatic cancer was 0.86, and risk was statistically significantly reduced among women with baseline body mass indexes (BMIs) of 25kg/m2 or higher (HR=0.71), but not among women with BMIs of less than 25kg/m2 (HR=1.62; P=0.01). According to the author, a low-fat dietary intervention was associated with reduced pancreatic cancer incidence in women who were overweight or obese.


Higher Brain Glucose Levels May Mean More Severe Alzheimer’s


According to an article published online in Alzheimer’s & Dementia: the Journal of the Alzheimer’s Association (6 November 2017), higher brain glucose levels may mean more severe Alzheimer’s, and thus showing connections between glucose metabolism and Alzheimer’s pathology, symptoms. For the first time, a connection was found between abnormalities in how the brain breaks down glucose and the severity of the signature amyloid plaques and tangles in the brain, as well as the onset of eventual outward symptoms of Alzheimer’s disease. For the study, the authors looked at brain tissue samples at autopsy from participants in the Baltimore Longitudinal Study of Aging (BLSA), one of the world’s longest-running scientific studies of human aging. The BLSA tracks neurological, physical and psychological data on participants over several decades. For the study, the authors measured glucose levels in different brain regions, some vulnerable to Alzheimer’s disease pathology, such as the frontal and temporal cortex, and some that are resistant, like the cerebellum. They analyzed three groups of BLSA participants: those with Alzheimer’s symptoms during life and with confirmed Alzheimer’s disease pathology (beta-amyloid protein plaques and neurofibrillary tangles) in the brain at death; healthy controls; and individuals without symptoms during life but with significant levels of Alzheimer’s pathology found in the brain post-mortem.


Results showed distinct abnormalities in glycolysis, the main process by which the brain breaks down glucose, with evidence linking the severity of the abnormalities to the severity of Alzheimer’s pathology. Lower rates of glycolysis and higher brain glucose levels correlated to more severe plaques and tangles found in the brains of people with the disease. More severe reductions in brain glycolysis were also related to the expression of symptoms of Alzheimer’s disease during life, such as problems with memory.


While similarities between diabetes and Alzheimer’s have long been suspected, they have been difficult to evaluate, since insulin is not needed for glucose to enter the brain or to get into neurons. The authors tracked the brain’s usage of glucose by measuring ratios of the amino acids serine, glycine and alanine to glucose, allowing them to assess rates of the key steps of glycolysis. Results showed that the activities of enzymes controlling these key glycolysis steps were lower in Alzheimer’s cases compared to normal brain tissue samples. Furthermore, lower enzyme activity was associated with more severe Alzheimer’s pathology in the brain and the development of symptoms.


Next, the authors used proteomics — the large-scale measurement of cellular proteins — to tally levels of GLUT3, a glucose transporter protein, in neurons. They found that GLUT3 levels were lower in brains with Alzheimer’s pathology compared to normal brains, and that these levels were also connected to the severity of tangles and plaques. Finally, the team checked blood glucose levels in study participants years before they died, finding that greater increases in blood glucose levels correlated with greater brain glucose levels at death.


According to the authors, the findings point to a novel mechanism that could be targeted in the development of new treatments to help the brain overcome glycolysis defects in Alzheimer’s disease. However, the authors cautioned that it is not yet completely clear whether abnormalities in brain glucose metabolism are definitively linked to the severity of Alzheimer’s disease symptoms or the speed of disease progression. The next steps for the authors include studying abnormalities in other metabolic pathways linked to glycolysis to determine how they may relate to Alzheimer’s pathology in the brain.


First Treatment Approved for Certain Patients with Erdheim-Chester Disease


Erdheim-Chester Disease (ECD) is a slow-growing blood cancer that originates in the bone marrow, and causes an increased production of histiocytes, a type of white blood cell. Excess histiocytes can result in tumors infiltrating many organs and tissues throughout the body, including the heart, lungs, brain and others. ECD is estimated to affect 600 to 700 patients worldwide. Approximately 54% of patients with ECD have the BRAF V600 mutation. Patients with ECD also have very limited life expectancies.


The FDA has expanded the approval of Zelboraf (vemurafenib) to include the treatment of certain adult patients with ECD. Zelboraf is indicated to treat patients whose cancer cells have the BRAF V600 mutation. This product was first approved in 2011 to treat certain patients with melanoma that harbor the BRAF V600E mutation. This is the first FDA-approved treatment for ECD.


Zelboraf is a kinase inhibitor that works by blocking certain enzymes that promote cell growth. The efficacy of Zelboraf for the treatment of ECD was studied in 22 patients with BRAF-V600-mutation positive ECD. The trial measured the percent of patients who experienced a complete or partial reduction in tumor size (overall response rate). In the trial, 11 patients (50%) experienced a partial response and 1 patient (4.5%) experienced a complete response. Common side effects of Zelboraf in patients with ECD include joint pain (arthralgia); small, raised bumps (maculo-papular rash); hair loss (alopecia); fatigue; change in the heart’s electrical activity (prolonged QT interval) and skin growths (papilloma). Severe side effects of Zelboraf include the development of new cancers (skin cancer, squamous cell carcinoma or other cancers), growth of tumors in patients with BRAF wild-type melanoma, hypersensitivity reactions (anaphylaxis and DRESS syndrome), severe skin reactions (Stevens-Johnson Syndrome and toxic epidermal necrolysis), heart abnormalities (QT prolongation), liver damage (hepatotoxicity), photosensitivity, severe reactions in the eye (uveitis), immune reactions after receiving radiation treatment (radiation sensitization and radiation recall), kidney failure and thickening of tissue in the hands and feet (Dupuytren’s contracture and plantar fascial fibromatosis). Zelboraf can also cause harm to a developing fetus; women should be advised of the potential risk to the fetus and to use effective contraception.


The FDA granted this application Priority Review and Breakthrough Therapy designations for this indication. Zelboraf also received Orphan Drug designation for this indication, which provides incentives to assist and encourage the development of drugs for rare diseases.


The FDA granted the approval of Zelboraf to Hoffman-LaRoche, Inc.


Bouffee de Petoncle de Mer

Is my French good? No. But this new recipe is. I was inspired to create this French title for my newest recipe, simply because it is so unbelievably delicious. It took time to get it right, but finally it is my great pleasure to share it with all of you. Your partner, spouse, guests will not believe that you made it; that’s how good it is, and easy, now that I’ve experimented with Jules, my best and favorite tester. The name of my recipe translates to: Puff of Sea Scallop, which is how it tastes. (if you like sea scallops).



1 pound very fresh sea scallops, rinsed and dried

1 pinch sea salt

1 pinch black pepper

2 teaspoons clam juice

6 fresh garlic cloves, sliced

One 2 inch piece of ginger, peeled then grated

6 scallions, thinly sliced (use the white part only)

Juice of 1/2 fresh lime

1 Tablespoon coconut flour

1/2 teaspoon baking soda

1/2 teaspoon baking powder

2 eggs but use the whites only, slightly beaten in a small cup

Extra virgin olive oil for cooking (or coconut oil or peanut oil)


You have to have a food processor for this recipe and a large skillet.


I bought the (real) sea shells for cooking, from Amazon. Even though you don’t have to use them, as you can see from the photos, serving in these shells, really adds to the presentation and the enjoyment. I highly recommend that you buy them. They’re not at all expensive.


Surprisingly, there’re not many ingredients in this wonderful recipe and all are easy to come by. I got the sea scallops from Whole Foods, the coconut flour from and all the rest from FreshDirect. ©Joyce Hays, Target Health Inc.



1. Get all your slicing, egg-separating, chopping, grating, done first.

2. Get out your food processor, a large skillet and the all-natural sea shells, for serving.

3. Make any number of sauces or toppings you want to use for the scallop puffs. I used an easy scallion cream sauce, a cashew cheese topping, mango chutney and pomegranate arils


Slicing scallions and grating the raw ginger. ©Joyce Hays, Target Health Inc.


In the photo above, all seasoning, garlic, scallions, grated ginger, clam juice, lime juice and egg whites have been added to the food processor. ©Joyce Hays, Target Health Inc.


In this photo, all of the previous ingredients have now been pulsed well. ©Joyce Hays, Target Health Inc.


4. All the ingredients are going to end up in your food processor, so it hardly matters, which goes in first, except, do this: add all of the dry ingredients last.


All the scallops were added and pulsed until all ingredients have been well combined. ©Joyce Hays, Target Health Inc.


Scallop Puff recipe ©Joyce Hays, Target Health Inc.


5. As you see above, add the dry ingredients to the food processor, last. Then, pulse until all ingredients have been completely and thoroughly combined. It’s important to do this right.

6. Next, with a narrow spatula, scrape all of the contents from your food processor, into a medium bowl. Get it all out, so it all goes into the Scallop Puffs


Scrape everything from the food processor, into a medium bowl. ©Joyce Hays, Target Health Inc.


7. Put oil in your large skillet and plan to cook no more than 3 or 4 Scallop Puffs at a time. Use a medium high flame and heat before cooking.

8. Rub some flour together, on your hands, then with a Tablespoon, scoop out of the bowl, some of the mixture, and with your other hand, form an oval shape while mixture is still in the Tablespoon, and plop it into the hot skillet, using fingers to get all of the mixture out of the Tablespoon. As you will see in the photos, there is no need to have each Puff look exactly the same. My concept was puffy clouds, none of which are ever the same.


All the Scallop Puffs will be slightly different shapes. ©Joyce Hays, Target Health Inc.


9. Cook 1 to 2 minutes on each side. Even though the flavor will be exquisite and delicate, you don’t have to be delicate while cooking, except to be sure they don’t burn. After flipping over the first time, you may see that this side needs to be cooked a little longer. Simply wait until the other side has cooked and browned, then flip back and cook a little longer, if needed. Both sides should be a golden brown, as you see in the photos.


Flipped too soon, so will cook second side until golden brown, then flip back and finish the first side. Important NOT to overcook, but get them the golden brown, that you see above. ©Joyce Hays, Target Health Inc.


10. Have the shells ready (or a serving platter), so that when cooked, put each Scallop Puff into its own shell and serve immediately with a sauce, with topping or plain which is just fine.


The Scallop Puffs are ready to serve. The fragrance is wonderful; you will NOT believe what a treat you’re in for. ©Joyce Hays, Target Health Inc.


The photos that follow, show a partial example of how the Scallop Puffs have been served, before sharing this new original recipe with you.


With scallion cream sauce. ©Joyce Hays, Target Health Inc.


After one bite and with scallion cream sauce. ©Joyce Hays, Target Health Inc.


Scallop Puff with Cashew Cheese Topping. ©Joyce Hays, Target Health Inc.


Nearly all eaten. Scallop Puff with Cashew Cheese Topping. ©Joyce Hays, Target Health Inc.


Scallop Puffs served plain with saffron rice and saut?ed broccoli. ©Joyce Hays, Target Health Inc.


Scallop Puffs served with saffron rice and mango chutney. Btw, the mango chutney is a fantastic combo with these Scallop Puffs. ©Joyce Hays, Target Health Inc.


Scallop Puff served with scallion cream and pomegranate arils. The seafood forks I used are one of my favorite stainless patterns, called: “Gone Fishing“ by the Japanese flatware company, Yamazaki. ©Joyce Hays, Target Health Inc.


Luscious Scallop Puff, half eaten with scallion cream sauce and pomegranate arils. ©Joyce Hays, Target Health Inc.


Scallop Puff extremely yummy with this scallion cream sauce and pomegranate arils. ©Joyce Hays, Target Health Inc.


The gourmet Scallop Puffs are as delicious as anything you could get at a good restaurant, probably as an appetizer and I am very proud of this. As for wine pairing, we prefer chilled white wine, or Proseco, or champagne or Blanc de Blancs. If you insist on a red, we would say, a very light-bodied red; however, the only red we’ve found that works well with seafood or fish is Hall’s cabernet sauvignon. ©Joyce Hays, Target Health Inc.


Weather here in Manhattan is now winter-y, we’ve added cozy plump puffy winter comforters for sleeping. Theater here continues to be stimulating and fun. We saw the comedy (which has extended the limited run, because it’s so popular) The Portuguese Kid, with Jason Alexander. This fine production is a fun-romp that’s light and playful. The acting is excellent, the constantly changing sets are terrific, the lighting design is perfect. If you liked the film, Moonstruck, you will love this play; they are like first cousins.


Hope you had a great week everyone!


From Our Table to Yours

Bon Appetit!